Communication Vital to End-of-Life Careby Jay

A year ago in March, I looked my father in the eyes for the last time as he mouthed the words “help me” from his ICU bed. But despite being surrounded by teams of medical personnel and the latest healthcare technology, I felt utterly powerless to make a clear decision—and unclear to whom to turn for sound advice.

After 30 days of care in a well-known teaching hospital in the Northeast, my father was about to succumb to Stage 4 lung cancer, a tumor invading his spine. Moments before his plea, the ICU team had conducted a breathing test that apparently went awry—beginning the trial while my mother and I were downstairs receiving the latest round of conflicting information from a pair of doctors debating his outlook for discharge, physical rehabilitation, and hospice care. They casually informed us that a breathing test was about to occur; we rushed back to my father’s side to learn the unfortunate outcome.

Prior to the episode that led to his being moved to the ICU, my father had been residing in a room directly across from a small hospitalist oncology office. What ensued was dizzying to behold: an endless parade of consultations; a narrowly averted million-dollar-plus spinal surgery in the wee hours; a too-zealous resident’s further injuring of my father’s right leg, which had already been compromised by a tumor degrading the femur.

My mother, my wife, and I struggled to maintain Dad’s always-indomitable spirit while parsing the barrage of input regarding his potential for quality of life outside the hospital. We sat in numerous meetings, often with a pair of doctors espousing diametrically opposed outlooks. We tried to keep track of whom we were speaking with and who was in charge at any given moment; the lists we kept looked like the roster of a sports team, amply covered in scribbled-out names, phone numbers—and question marks.

It was only after my father tried feebly to speak his last words to me that the doctor who’d appeared to be most in charge pulled me aside at the door of the ICU. My mother and I hemmed and hawed in trying to decide whether to accede to another round of heroic measures. I was surprised by the somewhat terse tone of voice this senior physician used in dissuading us from allowing further life-extending efforts. I would have welcomed such honesty wholeheartedly far earlier in the process.

One of the value propositions hospitalists tout to their employers and patients is their expertise in coordinating care and facilitating communication among caregivers. Of course, there are nearly as many methods for doing so as there are hospitalist teams.

As the medical process grows more complex and specialized, with more “stakeholders” weighing in on the conversation, the hospitalist’s role in taking charge of and energetically managing the flow of information for the benefit of beleaguered kin is more vital than ever. I can’t speak for all loved ones who must witness the passage of a parent, a child, or a spouse, but for me, a hospitalist’s firm hand would have made a world of difference in how we navigated this inevitable event.